Sunday, October 25, 2015

If the legislature wants to make the Medicaid program more complicated, it needs to commit to outreach

CONSULTANT JOHN STEPHEN: "I think you need to make the decision on...being able to do some work in the community."

The Health Reform Legislative Task Force is considering lots of new bells and whistles for the private option, the state's unique version of Medicaid expansion. But will the legislature be willing to provide the resources necessary for outreach, so that beneficiaries actually know what's going on and know how to navigate new programs? The state's recent track record on this front does not bode well.

The task force's consultant, the Stephen Group, released its final report this month; here are our overviews of the "in the box" and "out of the box" recommendations for changes. As we've covered, the potential changes — which would impose premiums on some beneficiaries, create a carrot-and-stick system incentivizing wellness and work training programs, and more — risk making the program more bureaucratic and imposing barriers to access to care on beneficiaries. Adding those layers of bureaucracy could be costly for the state. But whatever you might think of these policy ideas, one thing is clear: if you want to create complicated new wrinkles to the Medicaid program, you have to commit to outreach and education for beneficiaries. At least, you have to commit to outreach if you want the new policies to actually work.

The scheme envisioned by the Stephen Group could potentially be very complicated for beneficiaries. Even if it's relatively simple, it still demands that beneficiaries have a clear understanding of how the system works and how the incentives are supposed to line up. Keep in mind that many of these people have health insurance for the first time in their adult lives, and that the private option itself already adds layers of complexity beyond the traditional Medicaid program (in reporting on the private option's implementation, one of the most common themes I've heard from beneficiaries is confusion). If the legislature wants a wellness program or a work referral program to be meaningful — to actually impact behavior, as opposed to just making beneficiaries jump through hoops and piling up the administrative burden on state agencies — it has to have a robust plan for communicating with beneficiaries about their options. That means trusted outreach workers on the ground, in communities. That means education efforts, that means offering guidance along the way, that means establishing a smooth response system for questions. That means communication that is clear, consistent, ongoing, audience-appropriate, and user-friendly.

At a task force meeting earlier this week, the Stephen Group was asked why they recommended pulling the plug on the Health Independence Accounts — a program added to the private option this year that few beneficiaries participated in and that was costly to administer ($8.2 million annually, the cost split between the feds and the state). HIAs were intended to encourage consumerism but the system of incentives for beneficiaries was extremely confusing. Here's John Stephen, managing partner of the Stephen Group, on what went wrong:

I think the most important issue for us was that we felt—looking at the analysis— I don’t think there was a lot of outreach effort put into the legislation. In fact there was some discussion of no outreach at all. And you’re going to have these accounts and people don’t know — a lot of them don’t know about health care and how to use it appropriately, and they don’t know about these accounts.

The mention of "no outreach at all" is a reference to the 2014 amendment to the private option pushed by Rep. Nate Bell, which banned all state-appropriated funds for outreach related to the Affordable Care Act, including the private option. That includes grants fully paid for by the feds but routed through state agencies. Bell's special-language amendment, ironically, was offered in the same package of changes as the special-language amendment which created the HIAs. That zapped funding for hundreds of trained, federally funded In-Person Assister (IPA) Guides who were doing healthcare outreach work in the community, the sort of folks who might have come in handy when the state tried to implement a complicated new option for beneficiaries.

During this week's task force meeting, Sen. Missy Irvin (who, in fairness, seems genuinely interested in committing to better outreach/education) dismissed this backstory, saying, “At one time this legislature had a debate about navigators and those were folks hired to really navigate people towards the federal exchange … and not necessarily for this population.” But that's not the case. The legislature blocked federal funding for 100 additional IPA guides who would have been specifically designated for the private option. Meanwhile, the Bell amendment ended funding for more than 500 IPA guides who in fact were working both with the consumers shopping on the Marketplace that Irvin mentioned and with private option beneficiaries. The legislature also blocked millions of dollars in federal grant money for outreach that would have gone to the state's Insurance Department.

In short, not only is there zero evidence that the legislature is willing to commit resources to outreach or develop any sort of plan on this front, some GOP lawmakers in Arkansas are actually anti-outreach. Even when the feds were footing the bill, they turned up their nose. You can read some of the nonsense arguments offered up by lawmakers last year, but the gist is basically that if you have outreach workers informing people about their options, people might sign up for Obamacare, and Obamacare is bad.

One of the most consistent things I heard last year when I interviewed private option beneficiaries in communities across the state was how valuable the IPA guides were. Not just in terms of getting people to sign up in the first place, but also in helping them navigate the process, which was often confusing. The guide organizations were trusted groups that had extensive experience working directly with these communities. They spoke with people face to face — in community centers, at church, in people's homes. Their outreach work went well beyond getting people signed up. They checked up on folks and answered questions when an inevitably confusing piece of mail arrived from DHS or one of the insurance companies. They made sure they knew their options for accessing care. (I couldn't help but think of the IPA guides I saw at work in communities along the Delta when DHS had their fiasco with income verification; these were the folks that would know if someone's address changed, or could have knocked on doors to make sure they got the letters and knew what to do.)

The Stephen Group mentioned the outreach success in other states of guides and federal "navigators" (outreach workers similar to guides who had direct federal funding not routed through the state budget, and thus weren't impacted by the Bell amendment — around 30 had funding in Arkansas). But as the Stephen Group noted, guides/navigators are just one model for outreach. The private option will increasingly need more intensive work helping people use the health insurance that they have; while in practice the IPA guides were doing that work in the communities, their contracts focused on the enrollment side. Other stakeholders can and should also be involved in more robust outreach-and-education efforts going forward — insurance carriers, providers, insurance agents and brokers.

"You have resources in the community today," Stephen testified. "The independent agents. They meet with a lot of individuals on a one-to-one basis in the communities, representing the carriers. You have the carriers that are sending an information packet out in the mail to the communities, to the members. What is going on with followup there? That’s an opportunity. You have the primary care physicians that we’ve talked to in the community that we believe are willing to be a real significant player as well."

This will require not just a commitment of resources (and hopefully not turning down federal money to help!), but also a level of coordination, communication, and planning that we just haven't seen. Note that when the state sent out income-verification letters to private option beneficiaries — a group they knew would be hard to reach — carriers and brokers had no idea until the first batch of letters was already sent. The result: tens of thousands of eligible beneficiaries were kicked off of coverage because they didn't reply to a vague and confusing letter in time.

If the legislature and state agencies begin to think about how to make better use of existing resources, they should keep in mind what made the guides program work so well: its reliance on groups that were trusted in the community and had long experience working with the populations they were trying to reach. If you want to do effective outreach — in the Delta, in the Ozarks, in poor urban communities, among Spanish speakers, in transient populations, among the mentally ill — there are limits to what state bureaucrats or insurance companies can accomplish. These community groups will be key partners.

The Stephen Group's recommendations — not just the new incentives they suggest adding to the private option but also the broader goals of wellness and aiming to reduce health disparities among low-income populations in the state — all depend on effective outreach. Here's more from John Stephen, testifying before the task force earlier this week:

I think you need to make the decision on health disparity, education, and being able to do some work in the community. You could change that paradigm and dynamic with a little effort. ... States that have moved into the expansion…by and large have done a lot of outreach and education. Especially in areas…that have either health disparities or language barriers or other issues. You’re dealing with a population that has really never experienced the type of health care that everybody else has that’s not in that socio-economic status. There needs to be some type of education. That will go a long way. Especially in the meetings in the communities that we went to, hearing individuals that didn’t recognize the [value of] primary care, didn’t recognize the fact that this system of care is out there, there’s a behavioral health benefit that’s now that’s involved, and other issues.

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